Why patient satisfaction scores won’t decrease health care costs

So now, in addition to the many other bits of medical meddling we have from CMS (Centers for Medicare and Medicaid Services), there’s this.

Reimbursements to hospitals, from Medicare, will be partly tied to patient satisfaction scores. We’ve seen payments already being tied to ‘quality indicators,’ as dictated by the federal government; rewards for doing a better job on care for heart attacks, pneumonia, etc.. At least that’s quantifiable, whether scientifically correct or not.

But patient satisfaction scores? These scores, part of the constant ‘customer satisfaction’ trend in medicine, are fraught with peril. And despite the validation and complex statistical analysis, despite the way administrators love them and companies make money on them, the fact remains that customer satisfaction scores have downsides.

First of all, ask yourself when you fill out a satisfaction survey. Generally, I only do it when I’m unhappy with a product or service. If I’m happy, I’m too happy to bother with filling out paperwork.

Second, in facilities where satisfaction scores are highly regarded, physicians will tell you that they practice to enhance their scores; more specifically, that they practice to avoid being harassed by supervisors, to avoid losing income and to avoid losing their jobs…due to falling satisfaction scores. (Ironically, this is exactly the sort of thing the teacher’s unions complain about when it comes to performance based initiatives…teaching to the higher score. But at least those are also based on objective data points, rather than students filling out ‘teacher satisfaction surveys.’)

Third, those same physicians write to me in response to my ‘Second Opinion’ column in Emergency Medicine News, so I know their stories and struggles. They often feel great pressure to give things to people that they know are wrong, just to avoid low scores. For example, they are more likely to order the unnecessary test, or give the unnecessary narcotic, if they are under the microscope to attain high scores.

Fourth, don’t for a single minute think that patients don’t know this. Most don’t think this way, but a significant minority will use this as a bludgeon. ‘Guess I’ll have to complain about you, won’t I doctor?’ I’ve heard it and so have countless others.

Fifth and finally, how is it that Dr. Berwick, CMS administrator, can actually believe this will decrease costs? “This is one of those areas where improvement of quality and reduction in cost go hand-in-hand,” Dr. Berwick said. “My feeling continues to be that the best way for us to arrive at sustainable costs for the health care system is precisely through the improvement of quality of care.”

Obviously, quality can reduce costs. Missed diagnoses are expensive, and inefficient evaluation and treatment is expensive. And to the extent that some quality measures may give better outcomes sooner, and involve less follow-up care, it might be true. However, quality often involves cutting edge, innovative medicine which isn’t cheap…until the market gets hold of it down the line and the price drops, as in the case of high quality plastic surgery, or high quality LASIK surgery. Ultimately, however, the Medicare population is just sicker, and has a higher rate of complication and readmission. That variable isn’t changing soon. But reduction in cost and increased quality as functions of patient satisfaction? I’m dubious.

Let me get it straight: if you complain, you’ll get what you want, so that hospitals will get better scores. How will that decrease costs? ‘Nurse, I’m so happy, I’d like you to give me fewer medications and visit less often. Doctor, please don’t order anymore CT scans. I’m giddy with satisfaction!’

It’s all counter to human nature. And as usual, it’s a measure that the average medical foot-soldier will find reprehensible.

So how’s this: citizen satisfaction scores. We’ll hold back 1% of the salaries of CMS employees, senators and congressmen. If healthcare improves, we’ll bonus it out to those who were deemed most useful in implementing positive changes. It just might work! Somebody send me a survey…

Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of The Practice Test.

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I work as a hospitalist in New York City, and the administration at my hospital is very concerned about this new development. Linking patient satisfaction to reimbursement rates by CMS could translate into millions of dollars lost if your satisfaction rates are not up to par.

Thanks folks! This one really made me angry and nothing validates anger like knowing that other people are just as upset! We have to stick together on this one, knowing full well that some prominent physician in the media or somewhere else will prattle on about how important customer satisfaction is to the process, blah, blah, blah. We know the truth; this is a disaster in the making.

paul

the solution is to allow balance billing for money lost due to low satisfaction scores. people will start giving out all 5’s all the time if they realize anything lower will result in a big bill being sent to them. problem solved.

Marc Gorayeb, MD

Government oppression at its frustrating worst. It will chip away at you, nickel and dime you; suck the joy of practice out of you at a leech’s pace, to get you to yield to its illogical mandates.

Doug

Some interesting thoughts to ponder. One question and one thought for further discussion. First, the question: While intuition and experience may support some of the blog’s conclusions, can we point to data that supports the disastrous outcomes of linking patient satisfaction scores with decreasing health care costs? Second, I’ve heard the argument before that satisfaction surveys are completed primarily when we’re dissatisfied with the product, service, experience, etc. Maybe so. However, even if satisfaction surveys comparing hospitals of like size are based on dissatisfying patient experiences only, the feedback indicating “most” and “more” versus “less” and “least” dissatisfying patient experiences from facility to facility is still valuable in differentiating care and service.